title: High-dose neuroleptics and neuroleptic rotation for agitated delirium near the end of life.
abstract: Agitated delirium presents unique challenges for hospice and palliative care clinicians. Haloperidol, the recommended neuroleptic, may be ineffective at low dose, or poorly tolerated at higher doses.
  
  
  RESULTS
  This article reports on two patients with refractory agitated delirium. Both developed extrapyramidal symptoms from haloperidol and required rotation to an alternate neuroleptic. Patient #1 received 2000 mg/day oral chlorpromazine. Patient #2 received greater than 200 mg/day sublingual olanzapine. Control of agitation was achieved, though the doses were substantially higher than has previously reported in the literature. Each patient experienced considerable sedation, though this was an acceptable side effect for the family. Each patient was transferred from the acute care hospital to a location of family preference. There they died within a week of transfer.
  
  
  CONCLUSIONS
  Agitated delirium is a palliative care emergency. High doses of neuroleptic medications, with rotation to an alternate neuroleptic when side effects occur with standard haloperidol, may effectively palliate agitated delirium. This remedy can provide the patient with a peaceful dying in a place of their choosing.
authors.affiliation: Palliative Care Physician, Portland, OR, USA paulbbascom@gmail.com.
authors.forename: Paul B
authors.initials: PB
authors.lastname: Bascom
authors.affiliation: Portland Veteran's Affairs Medical Center, Oregon Health & Science University, Portland, OR, USA.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Bordley
authors.affiliation: Oregon Health & Science University, Portland, OR, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Lawton
mesh_terms: D000328:Adult; D014150:Antipsychotic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D003693:Delirium / Q000188:drug therapy*; D057915:Drug Substitution; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000150:complications; D015658:HIV Infections / Q000150:complications; D006220:Haloperidol / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011595:Psychomotor Agitation / Q000188:drug therapy*; D013727:Terminal Care / Q000379:methods*
chemical_list: D014150:Antipsychotic Agents; D006220:Haloperidol
keywords: agitated delirium; chlorpromazine; end-of-life care; olanzapine; palliative sedation; terminal delirium